Results - Medical and Public Health Management

5.4 Medical and Public Health Management

5.4.3 Results

5.4.3.1 Health profile

The life expectancy at birth in Nepal in 2012 was 68 years, 1 year longer than that of the WHO South-East Asia region and had increased by 6 years over the period from 2000-2012. The under-five mortality rate and the maternal mortality ratio have dramatically decreased in the latest decades although the prevalence of contraceptives, antenatal care and the rate of birth attended by skilled personnel is still below the average of the WHO region. Adult risk factors including raised blood glucose, raised blood pressure, obesity and tobacco use are average for the WHO region. The leading causes of death in Nepal are chronic obstructive pulmonary disease (COPD) (9.2%) followed by ischemic heart disease (9.2%), stroke (8.2%), lower respiratory infections (7%), and diarrheic disease (3.3%), with the latter two being among leading causes of child death. In both sexes in the period of 2000-2012, the increase of cardiovascular disease, diabetes and chronic respiratory disease are remarkable. Death due to HIV, tuberculosis and malaria is slightly increasing in both sexes.

Immunization against diphtheria, pertussis and tetanus (DPT) for 1-year-olds is increasing rapidly and reached more than 90%, which is better than the average of the WHO region (<80%) (WHO, 2015i).

Population using improved drinking water sources reached more than 80%, while the population using improved sanitation facilities are under 40% (WHO, 2015i). We visited water and wastewater facilities to investigate the availability of clean water and sewage system (see Bricker, Section 5.1. in this report).

The baseline hygiene situation in Nepal had very limited availability of potable water from a tap, although the water purification system is working at the upstream water intake, due to the limited and aged pipe system and the water pipe running parallel with the sewage system. People in suburban areas are using water from wells and sometimes directly drink water from wells.

5.4.3.2 Nutrition

By visiting UNDP Nepal Office, it was understood that Nepal was once a food exporting country, but now Nepal imports various foods from other countries. The PDNA also reports that undernutrition has been a longstanding problem especially in the affected area (Government of Nepal, National Planning Committee, 2015). Children, pregnant and lactating mothers and senior citizens had potential vulnerabilities because of undernutrition. Fig. 5.4.1. indicates the trend of children with undernutrition (<-2SD) in Nepal based on the growth standards of healthy children which can be achieved through healthy practices such as breastfeeding their children and not smoking during and after pregnancy regardless of ethnicity, socioeconomic status and type of feeding (WHO 2006). Malnutrition of women still occurs at a higher rate (24.4%) compared to developed countries, while the overweight population

is rapidly increasing (8.6%) as indicated in Fig. 5.4.2. Both trends, however, are showing the improving situation of nutrition in Nepal.

Fig. 5.4.1. Indicators of child malnutrition in Nepal.

(Source: WHO Nutrition Landscape Information System (NLiS), 2015) Definitions for Fig. 5.4.1.:

¥ Underweight: weight for age <-2 standard deviations (SD) of WHO Child Growth Standards median

¥ Stunting: height for age < -2 SD of the WHO Child Growth Standards median

¥ Wasting: weight for height < -2 SD of the WHO Child Growth Standards median

¥ Overweight: weight for height > +2 SD of the WHO Child Growth Standards median

Fig. 5.4.2. Malnutrition in women in Nepal.

(Source: WHO Nutrition Landscape Information System (NLiS), 2015) 5.4.3.3 Health problems in past disasters

DesInventar indicates the biggest cause of death related disaster in Nepal is epidemics (Fig. 5.4.3.). Fig.

5.4.4. indicates the trend of death by epidemics of any cause from 1971-2007 in Nepal indicating that infectious disease related death has remained very common even until recently.

is rapidly increasing (8.6%) as indicated in Fig. 5.4.2. Both trends, however, are showing the improving situation of nutrition in Nepal.

Fig. 5.4.1. Indicators of child malnutrition in Nepal.

(Source: WHO Nutrition Landscape Information System (NLiS), 2015) Definitions for Fig. 5.4.1.:

¥ Underweight: weight for age <-2 standard deviations (SD) of WHO Child Growth Standards median

¥ Stunting: height for age < -2 SD of the WHO Child Growth Standards median

¥ Wasting: weight for height < -2 SD of the WHO Child Growth Standards median

¥ Overweight: weight for height > +2 SD of the WHO Child Growth Standards median

Fig. 5.4.2. Malnutrition in women in Nepal.

(Source: WHO Nutrition Landscape Information System (NLiS), 2015) 5.4.3.3 Health problems in past disasters

DesInventar indicates the biggest cause of death related disaster in Nepal is epidemics (Fig. 5.4.3.). Fig.

5.4.4. indicates the trend of death by epidemics of any cause from 1971-2007 in Nepal indicating that infectious disease related death has remained very common even until recently.

Fig. 5.4.3. The number of death by disaster types in Nepal (available at

http://www.desinventar.net/DesInventar/profiletab.jsp?countrycode=nplretrieved on Jan. 10, 2016)

Fig. 5.4.4. Trends of deaths caused by epidemics in Nepal from 1971-2007 (Graph created by DesInventar http://online.desinventar.org/desinventar/#NPL-DISASTER on Jan. 7, 2016).

We classified the names of diseases into diarrhea, fever, nervous system, respiratory and others according to observations about the cause of disaster in each record of DesInventar. If there is no specific description about the disease, it was categorized unknown including diseases in animals and plants. As shown in Fig. 5.4.5., diarrheic diseases, including cholera and dysentery, was the biggest cause of death in past disasters.

Fig. 5.4.5. Number of deaths and affected people by epidemics in disaster in Nepal 1971-2007 according to DesInventar data.

5.4.3.4 Health care system preparedness for disaster

The Institute of Medicine, Tribhuvan University (IOM-TU) is the oldest national medical school in Nepal and most medical doctors and government authorities are graduates from IOM-TU. With the administration of MoHP, virtually every district now has medical colleges and hospitals as tertiary hospitals. Regional experts established the Program for Enhancement of Emergency Response (PEER), which includes Hospital Preparedness for Emergencies (HOPE), since 2004 in collaboration with MoHP and Johns Hopkins University in the U.S.A. PEER is managed by MoHP and the Asian Disaster Preparedness Center (ADPC) and National Society for Earthquake Technology (NSET) to train healthcare workers and administration staff and mainstream disaster risk reduction in all developments.

PEER is operational in nine countries and funded by United States Agency for International Development - Office of U.S. Foreign Disaster Assistance (USAID-OFDA), with supplemental support from American Red Cross (ARC) (Asian Disaster Preparedness Center, 2011). HOPE addresses structural, non-structural, organizational and medical concerns of health facilities in order to improve capacity to respond effectively to emergencies. The first course of HOPE was conducted in Nepal in 2004, institutionalized by NSET and successfully continuously organized by IOM-TU. IOM-TU conducted HOPE in the five other countries (Bangladesh, India, Indonesia, Pakistan and the Philippines) in the region and MoHP supported the budget for this activity. HOPE was modified to cope with multi-hazards. Instructors’ capacities are strengthened through multi-step learning and teaching experiences to be able to organize and evaluate the courses including various units of disaster medical and public health management. Hospital administrators, engineers, physicians, nurses and planning staff are the candidates for the course. The HOPE course includes interactive lectures and discussions, case studies and a variety of exercises and simulations. The following topic are lectured (from the web page of TU-IOM http://www.iom.edu.np/?page_id=106 retrieved on Jan 10, 2016).

¥ Overview of Disasters

¥ Disaster Risk Management

¥ Disaster Epidemiology and Patterns of Injury

¥ Hazards

¥ Structural Components

Fig. 5.4.5. Number of deaths and affected people by epidemics in disaster in Nepal 1971-2007 according to DesInventar data.

5.4.3.4 Health care system preparedness for disaster

¥ Overview of Disasters

¥ Disaster Risk Management

¥ Disaster Epidemiology and Patterns of Injury

¥ Hazards

¥ Structural Components

¥ Non Structural Components

¥ Functional Collapse of Hospitals

¥ Pre- Hospital Care

¥ TRIAGE

¥ Emergency Department

¥ Principles of Disaster Medicine

¥ Hospital Emergency Incident Command System (HEICS)

¥ Hospital Preparedness Planning

¥ Techno-Industrial Disasters

¥ Complex Emergencies

¥ Mass Casualty Incident

¥ Mass Gathering Event

¥ On-Site Medical Care

¥ Psychosocial Consequences of Disaster

¥ Inter-agency Coordination

¥ Hospital Internal Disaster

¥ Mass Fatality Management

¥ Disaster Risk Communications

¥ Resource Management

¥ Epidemics and Emerging Infections

¥ Return to Normal Health Operations

WHO and Nepal have been implementing the WHO Country Cooperative Strategy (CCS) 2013-2017 (WHO 2012). Reducing the health consequences of natural and human induced disasters is one of the strategic priorities, recognizing that the health sector is particularly prone to the effects of disasters because of the country’s geographic and population size, which translates to a limited margin of human, material and financial resources. CCS also recognizes that disasters tend to have a twofold impact on health systems: directly, through damage to the infrastructure and health facilities and the consequent interruption of services at a time when they are most needed; and indirectly, by potentially causing an unexpected number of casualties, injuries and illnesses in affected communities (WHO, 2012). The expected hazards in the CCS of 2012 included floods, landslides, earthquake, fire, epidemics as well as the effects of climate change, avian influenza, industrial accidents, explosions of improvised explosive devices, road accidents and poisoning i.e. multi-hazard preparedness. In seismic vulnerability ranking, Kathmandu valley was placed top of the global hazard map expecting MMI 9-11.

CCS also recognizes epidemics as disasters including cholera and gastroenteritis. The Government of Nepal implemented an Early Warning and Alert Response Surveillance (EWARS) system to detect any epidemics using sentinel sites all over the country, but cases from communities not visiting hospitals are not reflected in the surveillance data. The strategic priority of CCS to reduce the health consequences of disasters focuses on the following two topics and respective approaches (WHO, 2012).

5.1. Strengthen national capacity and coordination in health sector emergency risk management;

Strategic approaches

5.1.1: Advocate for adequate human resources in the area of health sector emergency preparedness at all levels.

5.1.2: Strengthen the tools, skills and support systems to enable district health systems to undertake initiatives in emergency risk management.

5.1.3: Provide technical support to programmes for reducing the vulnerability of health facilities to the effects of disasters in accordance with the National Disaster Risk Reduction Strategy and hospital safety initiatives.

5.2. Promote and support a coherent intersectoral approach to health emergency preparedness and response including recovery.

Strategic approaches:

5.2.1: Provide technical and policy support for the development and implementation of an intersectoral mass casualty management strategy.

5.2.2: Strengthen partnerships with Government, nongovernmental and civil society organizations for more effective planning, coordination, and response linking with the existing Inter Agency Standing Committee (IASC).

5.4.3.5 Reality of the Nepal Earthquake 2015 5.4.3.5.1 Outline of health impact

The M 7.8 Nepal Earthquake 2015, on Saturday (a holiday in Nepal) Apr. 25, and the biggest aftershock, M 7.3 on May 12, resulted in 8,898 deaths, 22,309 injuries, 7,324 surgeries performed, 5.6 million people affected, and 2.8 million people displaced as of Aug. 6, 2015 (WHO, 2015h). Of the total impact, 141 deaths and 3159 injuries were attributed to the May 12 earthquake (WHO, 2015c).

Health Cluster Bulletins (WHO, 2015a-h) reported the increasing number of dead, lost and injured as well as cases treated according to the updates as shown in Fig. 5.4.6. It took more than a month to finalize the accurate numbers of human health damage. The number of health cluster partners had two peaks at 2 and 8 weeks after the disaster. It is remarkable that the cumulative number of cases treated is far bigger than the number of injuries and reached more than 100,000 after one month. Considering that the final numbers of injuries and surgeries were fixed at 202,309 and 7,324 respectively at the beginning of June, and outbreak of infectious diseases was minimal, most of the treatment could be due to that of non-trauma and non-communicable disease (NCD). Another reason of the increased number of cases treated can be the cumulative counting of repeated treatments of a single patient. The requested amount of funds for the health sector was finalized at 41.8 million USD which was gradually covered up to 45.8% as of Aug. 2, 2015.

Fig. 5.4.6. Trends of health damage and response according to the WHO Health Cluster Bulletins.

0 50 100 150 200 250 300 350 400 450

0 20000 40000 60000 80000 100000 120000

4/26/15 5/10/15 5/24/15 6/7/15 6/21/15 7/5/15 7/19/15 8/2/15

Health cluster partners and %Fund covered Number of dead, injured, case treated and admission

Date

Dead Injured case treated admission Health cluster partners

% Fund covered

5.2. Promote and support a coherent intersectoral approach to health emergency preparedness and response including recovery.

Strategic approaches:

5.2.1: Provide technical and policy support for the development and implementation of an intersectoral mass casualty management strategy.

5.4.3.5 Reality of the Nepal Earthquake 2015 5.4.3.5.1 Outline of health impact

Fig. 5.4.6. Trends of health damage and response according to the WHO Health Cluster Bulletins.

0 50 100 150 200 250 300 350 400 450

0 20000 40000 60000 80000 100000 120000

4/26/15 5/10/15 5/24/15 6/7/15 6/21/15 7/5/15 7/19/15 8/2/15

Health cluster partners and %Fund covered Number of dead, injured, case treated and admission

Date

Dead Injured case treated admission Health cluster partners

% Fund covered

5.4.3.5.2 Good practices 5.4.3.5.2.1 Hospital retrofitting

Since Nepal is an earthquake prone country, retrofitting of the hospitals was achieved at a high rate especially in Kathmandu where most hospitals are located. All but four referral hospital remained standing (WHO, 2015a). All Kathmandu hospitals continued functioning after the May 12 earthquake (WHO, 2015c). MoHP developed Standard Guidelines for the Post-disaster Reconstruction of Health Facilities (WHO, 2015f). Slightly more than 100 days into response, 99% of damaged health facilities has resumed services across affected districts. (WHO, 2015h).

5.4.3.5.2.2 Medical assistance and coordination

Surge capacities were distributed to the hospitals by health cluster, to provide a “hub and spoke”

approach. Four non-functioning district hospitals were replaced with field hospitals. Foreign Medical Teams (FMTs) were encouraged to treat NCDs. WHO Treatment guidelines for NCDs were distributed to health professionals to calculate the required amount of medicine using the gender-disaggregated data of the districts. Assessment of remaining hospitals identified the necessity of urgent assistance (WHO, 2015a). More than 200 national medical teams and about 100 FMTs substituted for the non-functioning health facilities of severely affected districts. These FMTs were deployed by the health cluster. Push type provision of essential medicines and supplies were done. MoHP provided trauma treatment protocols to FMTs to avoid unnecessary over treatment including amputation. Alternative care and rehabilitation was established to decrease the congestion of the hospitals by admitted patients who need long-term care (WHO, 2015a).

Daily health cluster meetings were conducted immediately after the disaster. MoHP updated the partners daily, and the meeting notes were circulated to the partners every evening. The Health Cluster participates in Inter-Cluster meetings and the WASH Cluster. A working group for post-trauma rehabilitation was suggested. The Health Cluster invited Camp Coordination and Camp Management Clusters to update partners on health issues. Hubs were set up in Gorkha and Dhading Districts (WHO, 2015a). Operational Health Cluster meetings were started in Gorkha and Sindhupalchok. The Health Cluster mapped partners’ abilities and facilities for effective coordination (WHO, 2015b).

FMTs substituted for critical infrastructure and worked closely with District Health Offices (DHOs) and reported the end of their work, exit plans and transition strategies as needed. A coordination desk was established at Tribhuvan Airport for a referral service of critical patients airlifted from affected districts (WHO, 2015b). Exits of FMTs were coordinated by the Health Cluster to avoid gaps in services. The remaining 58 FMTs faced the May 12 earthquake but restarted the treatment of surge patients immediately. Two FMTs withdrew in light of safely concerns (WHO, 2015c). To evaluate the effectiveness of FMTs, survey forms were developed and distributed to FMTs. The survey is kept anonymous and confidential.

5.4.3.5.2.3 On-site training of health professionals

Rapid deployment of health professionals supported affected health facilities, even in remote areas.

Hospitals in Kathmandu were adequately staffed (WHO, 2015a). Standardized Interagency Emergency Health Kits (IEHK) were supplied from multiple donors (WHO, 2015b). About 1,000 health personnel were trained by the China Medical Team in laboratory tests, specimen collection, field disinfection, surveillance of infectious disease, health promotion and post-disaster psychological assistance, etc.

(WHO, 2015d). The Injury Rehabilitation sub-cluster trained carers, paramedics and nursing staff to identify patients requiring rehab and in the handling of complex trauma patients. Training about emerging infectious diseases, especially dengue, was provided (WHO, 2015f).

MoHP carried out capacity building of health workers about disaster risk reduction including Mass Casualty Management (MCM) and Hospital Preparedness for Emergency (HOPE) programs. Even with limited resources and under the most challenging circumstances, a group of people,

notwithstanding their own personal tragedies, who are truly compassionate, ethical and determined to save lives and provide relief, could make all the difference (WHO, 2015f).

5.4.3.5.2.4 Trauma and injury

More than 20,000 people were injured in the disaster and a third of patients required follow up care and rehabilitation. The number of trauma patients started decreasing in a week. Hospital staff dealt well with injuries and no gaps in surgery and trauma care were identified (WHO, 2015a). The Injury Rehabilitation Sub-cluster was established. The Health Cluster developed an assisted discharge system to encourage patients, including issuing ID cards and follow-up services for free. Hub hospital coordinators were assigned to collect detailed information about the status and medical needs of discharged patients (WHO, 2015b).

5.4.3.5.2.5 Surveillance and infectious disease

Although some cases of diarrhea were found, no remarkable outbreak of infectious diseases was reported. WHO supported MoHP to assess the severely affected districts. NGOs shared their assessments with the Health Cluster. MoHP introduced prospective syndromic surveillance using the observation of the out-patient department of hospitals (WHO, 2015a). Many NGOs helped the assessment using electronic assessment tools (WHO, 2015b). Establishment of EWARS including zero-reporting and its daily reports indicated a decrease of epidemic-prone diseases and trauma.

Surveillance focused on four symptoms of acute respiratory infection, acute watery diarrhea, acute bloody diarrhea and fever of unknown origin from 60 sentinel surveillance sites that consisted of all district hospitals, private hospitals and FMT camps in the 14 severely affected districts. Rumors of suspicious outbreaks were verified by multiple channels and most rumors were denied.

Rapid detection of epidemic-prone diseases and intervention prevented outbreaks. Stool samples have tested negative for Vibrio cholera, Shigella and Salmonella (WHO, 2015b). EWARS continuously indicated the decrease of epidemic-prone diseases. Field laboratory facilities also confirmed no outbreaks of diarrheic pathogens or malaria vectors (WHO, 2015c). As the situation settled down, the surveillance form was revised to normalize the disease spectrum (WHO, 2015e).

TB and HIV patients were advised to seek continuous medical treatment for free to avoid the development of drug resistance. The National Tuberculosis Center conducted post-disaster rapid assessment of national tuberculosis program including rapid assessment of functionality of DOTS (Directly Observed Treatment System). The result facilitated the promotion of DOTS recovery and psychosocial support of patients. At least 517 (83.6%) of 698 TB patients and 134 (88.7%) of 151 drug resistant TB patients continued anti-TB treatment after the Apr. 25 earthquake (WHO, 2015d).

Immunization for vaccine preventable diseases was promoted especially for children under five (WHO, 2015g).

5.4.3.5.2.6 Mental health

The sub-cluster for Mental Health was established by WHO, MoHP and TU-IOM, and initiated from the three hardest hit districts. For the past three years, primary health care centers were providing mental health care with support from mental hospitals and these initiatives were strengthened by permanent teams consisting of one psychiatrist, one psychologist and two supporting staff. The psychosocial working group under the Social Protection Cluster also supported this (WHO, 2015a). Mobile teams of mental health care were deployed. WHO emphasized the importance of giving time for natural recovery rather than medicalizing the problem. In Dhading district, psychosocial treatment and counseling was

notwithstanding their own personal tragedies, who are truly compassionate, ethical and determined to save lives and provide relief, could make all the difference (WHO, 2015f).

5.4.3.5.2.4 Trauma and injury

5.4.3.5.2.5 Surveillance and infectious disease

Immunization for vaccine preventable diseases was promoted especially for children under five (WHO, 2015g).

5.4.3.5.2.6 Mental health

implemented, which attracted many people (WHO, 2015b). Mental Hospital, Patan, deployed a mental health team to Dhading district and provided psychosocial support in the form of psychological first aid (PFA) and relaxation therapy. On average, 30-40 persons per day visited this service. PFA was provided to more than 1,500 people (WHO, 2015c).

Department of Psychiatry and mental health TUTH responded with the establishment of a ‘24 hour crisis intervention and psychological help desk which was aimed to provide immediate psychosocial support for those who were suffering acute psychological reaction in response to the earthquake. The out-patient department was functional immediately and there was no breach in the in-patient care.

Psychiatry services were also provided to triage area in the emergency at TUTH and Trauma center at Bir hospital.

Many on-site trainings to health workers, teachers, media persons about psychosocial interventions in trauma, and psychological first aid was provided by the department. The department also provided mental health services at Chautara in Sindhupalchowk, one of the major disaster affected areas in the country.

The Psychiatrist Association of Nepal dispatched mental health and psychosocial support teams and managed mobile mental health camps in the affected area (WHO, 2015d). Psychosocial support was provided to teachers and children in schools (WHO, 2015g). Psychosocial support was also provided to older persons through health camps (WHO, 2015h).

5.4.3.5.2.7 Maternal care and care for children

In the 14 severely affected districts, 60,000 pregnant women and 10,000 deliveries were expected every month. Each month, 1,500 women may have complications during pregnancy and childbirth requiring medical care (WHO, 2015b). Six hospitals were identified as referrals for emergency obstetrics and the Sub-Cluster for Reproductive Health was established. UNICEF provided 50,000 neonatal kits. This Sub-Cluster developed a standard assessment form for reproductive health care services. Pre- and post-delivery care was provided through a national reproductive health care protocol for standardized care. The Child Health Working Group was also established and distributed flip charts for Integrated Management of Childhood Illness to hospitals and FMTs. District Public Health Officers conducted vaccinations for measles, mumps and rubella (MMR) (WHO, 2015a). Guidance notes for parents/care-takers on counseling for children after natural disaster were developed and disseminated.

Equipment and supplies for reproductive health were adequately reached and provided. Resuming maternity services in the damaged facilities were accelerated (WHO, 2015b). Shelter homes were established for pregnant women with complications, postnatal mothers, newborns and children under five who have been left homeless to have safe place to stay after being discharged from hospitals. Drugs and materials to prevent postnatal hemorrhage and infection were distributed adequately (WHO 2015c).

5.4.3.5.2.8 Advocacy of hygiene and sanitation

WHO, Water Sanitation Hygiene (WASH) Cluster and Non-Governmental Organizations (NGOs) helped health facilities restore water and sanitation facilities. Mobile water quality testing laboratories were set up. Pit latrines were built in temporary shelters. A regular supply of water, chlorine tablets and hygiene materials were ensured (WHO, 2015a). Quality of water sanitation was strictly monitored and the contaminated water was corrected by increasing the residual chloride levels. WHO helped the WASH Cluster in health facilities. Health information was provided through Female Community Health Volunteers (FCHV) with the help of the National Health Education Information and Coordination Center (NHEICC) for wider outreach. Health related posters and leaflets were disseminated (WHO, 2015b). Six key hygiene messages were broadcast from local radio stations in the severely affected districts. Post-earthquake communication plan was also finalized by NHEICC to promote the hygiene aspects of shelters (WHO, 2015d). Health information from local health centers

through radio station and SNS were disseminated in many districts (WHO, 2015g). In Patan Hospital, which we visited, the community donated foods for patients, but the hospital accepted only uncooked materials and processed the food for the patients inside the hospital to avoid food and water-borne infectious disease.

5.4.3.5.2.9 Logistics

The World Food Program (WFP) as the logistics center was building a test operation center next to the Kathmandu airport for training just before the earthquake. It immediately served as the real logistic center accepting and supplying the supporting materials (see Das, section 5.2 of this report). WFP transports all goods and supplies, except human resources, to distant areas. Due to the limited and costly air transport, ground transportation and sometimes porter and cargo animals delivered materials to mountainous area. WFP never dropped materials from the air to assure face-to-face delivery.

The Government of Nepal encouraged people to leave Kathmandu Valley to help the people in their home towns, which significantly decreased congestion within the city so that emergency vehicles could operate more smoothly. The recovery of communication tools including cell phones were relatively quick and there had been no lack of fuel for cars. Medical Camp Kits were created and set up by WHO and WFP as temporary field hospital facilities replacing primary health care facilities in the highly affected areas before permanent restoration, due to expected monsoons (WHO, 2015d).

5.4.3.5.3 Gaps

5.4.3.5.3.1 Preparedness

A WHO rapid assessment team found the hospitals were in shortage of a range of critical medical supplies, including emergency medicines, surgery kits, IV fluids, antibiotics and suturing materials (WHO, 2015a). Regular supply and buffer stock of medicine and other essential supplies in remote areas needs to be ensured. Prepositioning of supplies for at least three months will ensure the continuity of services even after roads are inaccessible during the peak of monsoon season (WHO, 2015g).

Outside Kathmandu Valley, 40% of approved posts for health workers were vacant even before the earthquake (WHO, 2015a).

5.4.3.5.3.2 Vulnerability of building architecture

Buildings of Nepal have historical value and retrofitting for seismic strengthening was not promoted sufficiently, although people and the national government were aware of the earthquake prone nature of the country. Frequent aftershocks, especially the May 12 earthquake, prompted fear among people and some people fell down from heights. The building code had been implemented long before the earthquake according to the international standards for seismic strength, but during construction after the approval from the municipal office, the level of actual strength deteriorates. The culture in Nepal regards upper floors as better place for living and the limited land area made the upper part of the houses heavier.

Falling adobe and bricks of the building without reinforcement fell down and caused injuries, and also caused the collapse of buildings and houses resulting in the frequent major injuries such as bone fracture, head and spinal injuries.

5.4.3.5.3.3 Safe hospitals

Four district hospitals ceased functioning due to infrastructure damage. Damaged infrastructure and limited materials, lack of medical supplies and essential medicine in the hospitals deteriorated the function of remaining hospitals. Some services were interrupted for more than 100 days because of landslides and road blockage in monsoon season. Eighteen health workers and volunteers lost their lives and 75 were injured in the disaster (WHO, 2015h).

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